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NYU Medical Grand Rounds
Clinical Vignette
Benjamin Eckhardt, MD
PGY-3
October 6, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 39-year-old man presenting with three days of
fever, cough, and shortness of breath.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient reported abrupt onset of subjective fevers,
chills and headaches three days prior to admission.
•He noted his cough to be progressively worsening
with minimal sputum production.
•On the day of admission, the patient’s symptoms
progressed to include shortness of breath.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•None
•Past Surgical History:
•None
•Social History:
•From China, came to the United States four years prior to admission
•Works in a restaurant
•Denies recent travel or sick contacts
•Denies toxic habits
•Family History:
•noncontributory
•Allergies: No Known Drug Allergies
•Denies any Medications
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: Ill-appearing man in moderate respiratory
distress
•Vital Signs: T:103.9 BP:104/49 HR:126 RR:25
O2 Sat: 83% on room air → 97% on
100% non-re-breather
•Course rhonchi throughout lung fields, no wheezing
•Cool extremities
•The remainder of Physical Exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
CBC: White blood cells 7, 88% Neutrophils
Remainder of CBC was within normal limits
Hepatic Function Panel: AST: 98, ALT: 64
Remainder of LFTs were within normal limits
Basic Metabolic Panel was within normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
Lactate Dehydrogenase: 629 (110-225)
Influenza A Ag: positive
Influenza B Ag: negative
Blood cultures and Urine cultures: No Growth
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Admission Chest X-Ray
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Cat Scan
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Cat Scan
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Cat Scan
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working or Differential Diagnosis
Influenza pneumonia with Acute Respiratory
Distress Syndrome
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• The patient’s respiratory status worsened in the
emergency room requiring intubation
• The patient was started broad spectrum anti-microbials,
and admitted to the medical intensive care unit.
• The antimicrobials included:
–
–
–
–
Oseltamivir 150mg twice daily
Vancomycin 1g twice daily
Piperacillin/tazobactam 4.5g four times daily
Azithromycin 500mg daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• The patient remained febrile and dependent on
ventilatory support after completing a five day
course of oseltamivir and azithromycin
• Hospital 7:
Due to the patient’s persistent fevers he was
switched to imipenem and restarted on the antivirals oseltamivir and rimantidine
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital day 8:
Oseltamivir was replaced by intravenous peramiver
after being acquired from the Centers for Disease
Control
• Blood cultures, urine cultures, tracheal aspirate
cultures, Human Immunodeficiency Virus testing,
sputum Acid Fast Bacilli testing and urine legionella
antigen were all negative
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 12:
A bronchoscopy was performed with negative gram
stain, Acid Fast Bacilli, Respiratory Syncytial
Virus Polymerase Chain Reaction, bacterial
culture and viral culture
• Hospital Day 15:
Antibiotics and antivirals were discontinued for
worsening pancytopenia
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 16:
Antiobiotics were restarted (cefepime then
tigecycline) for neutropenic fever
• Hospital Day 19-34:
The patient’s Hemodynamics improved and
vasopressors were weaned off. His fevers abated
and his respiratory status improved allowing for
capping of his tracheostomy. Additionally the
patient’s blood counts improved and the patient was
discharged home on hospital day 34.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
•Influenza pneumonia complicated by acute
respiratory distress syndrome
•Pancytopenia likely secondary to infection
versus medication effect.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS